Common use of MLTC enrollment Clause in Contracts

MLTC enrollment. Including the protections afforded individuals in subparagraph (c) of this STC, the following requirements apply to MLTC plan enrollment. i. Transition of care period. Initial transition into MLTC from fee-for-service: Each enrollee who is receiving community based long-term services and supports that qualify for MLTC must continue to receive services under the enrollee’s pre-existing service plan for at least 90 days after enrollment, or until a care assessment has been completed by the MCO/PIHP, whichever is later. Any reduction, suspension, denial, or termination of previously authorized services shall trigger the required notice under 42 CFR § 438.404 which clearly articulates the enrollee’s right to file an appeal (either expedited, if warranted or standard), the right to have authorized service continue pending the appeal and the right to a fair hearing if the plan renders an adverse determination (either in whole or in part) on the appeal. For initial implementation of the auto-assigned population, the plans must submit data for state review on a monthly basis reporting instances when the plan has issued a notice of action that involves a reduction of split shift or live-in services, or when the plan is reducing hours by 25% or more. The plan will also report the number of appeals and fair hearing requested regarding these reductions. The state shall ensure, through its contracts, that if an enrollee is to change from one MCO/PIHP to another, the MCO/PIHPs will communicate with one another to ensure a smooth transition and provide the new MCO/PIHP with the individual’s current service plan.

MLTC enrollment. Including the protections afforded individuals in subparagraph (c) of this STC, the following requirements apply to MLTC plan enrollment. i. Transition of care period. Initial transition into MLTC from fee-for-for- service: . Each enrollee who is receiving community community-based long-term services and supports that qualify qualifies for MLTC must continue to receive services under the enrollee’s enrollee‟s pre-existing service plan for at least 90 60 days after enrollment, or until a care assessment has been completed by the MCO/PIHP, whichever is later. Any reduction, suspension, denial, denial or termination of previously authorized services shall trigger the required notice under 42 CFR § 438.404 which clearly articulates the enrollee’s enrollee‟s right to file an appeal (either expedited, if warranted warranted, or standard), the right to have authorized service continue pending the appeal appeal, and the right to a fair hearing if the plan renders an adverse determination (either in whole or in part) on the appeal. For initial implementation of the auto-assigned population, the plans must submit data for state review on a monthly basis reporting instances when the plan has issued a notice of action that involves a reduction of split shift or live-in services, services or when the plan is reducing hours by 25% 25 percent or more. The plan will also report the number of appeals and fair hearing hearings requested regarding these reductions. The state shall ensure, ensure through its contracts, contracts that if an enrollee is to change from one MCO/PIHP to another, the MCO/PIHPs will communicate with one another to ensure a smooth transition and provide the new MCO/PIHP with the individual’s individual‟s current service plan. ii. MLTC Eligibility. MLTC plans conduct the initial programmatic eligibility determination for plan enrollment using a standardized assessment tool designated by the state. The following requirements apply to the activities that must be undertaken by a MLTC plan as it assesses applicants for enrollment in the plan. 1. The state shall ensure all individuals requesting long-term services and supports are assessed for MLTC eligibility. a. The MCO/PIHP will use the Semi-Annual Assessment of Members (SAAM) tool (or successor tool designated by the state) to determine if the individual meets the eligibility criteria to be enrolled in an MLTC. b. In addition to the SAAM tool, the MCO/PIHP may use other assessment tools as appropriate. The state must review and approve all other assessment tools used by the MCO/PIHP. c. The state must ensure through its contracts that each MCO/PIHP must complete the initial assessment in the individual‟s home of all individuals referred to or requesting enrollment in an MLTC plan within 30 days of that referral or initial contact. MCO/PIHP compliance with this standard shall be reported to CMS in the quarterly reports as required in STC 62. 2. The MCO/PIHP shall complete a re-assessment at least annually, or at another timeframe as specified in the MCO/PIHP contract. 3. The state shall require each MCO/PIHP, through its contract, to report to the enrollment broker the names of all individuals for whom an assessment is completed. If the individual has not been referred by the enrollment broker, the MCO/PIHP shall report the date of initial contact by the individual and the date of the assessment to determine compliance with the 30-day requirement. a. The state shall use this information to determine if individuals have been wrongfully determined ineligible. b. The state shall review a sample of those assessments at least annually, either through the EQRO or by the state, to verify the correct determination was made.

MLTC enrollment. Including the protections afforded individuals in subparagraph (c) of this STC, the following requirements apply to MLTC plan enrollment. i. Transition of care period. Initial transition into MLTC from fee-for-service: . Each enrollee who is receiving community based long-term services and supports that qualify for MLTC must continue to receive services under the enrollee’s pre-existing service plan for at least 90 60 days after enrollment, or until a care assessment has been completed by the MCO/PIHP, whichever is later. Any reduction, suspension, denial, or termination of previously authorized services shall trigger the required notice under 42 CFR § 438.404 which clearly articulates the enrollee’s right to file an appeal (either expedited, if warranted or standard), the right to have authorized service continue pending the appeal and the right to a fair hearing if the plan renders an adverse determination (either in whole or in part) on the appeal. For initial implementation of the auto-assigned population, the plans must submit data for state review on a monthly basis reporting instances when the plan has issued a notice of action that involves a reduction of split shift or live-in services, or when the plan is reducing hours by 25% or more. The plan will also report the number of appeals and fair hearing requested regarding these reductions. The state shall ensure, through its contracts, that if an enrollee is to change from one MCO/PIHP to another, the MCO/PIHPs will communicate with one another to ensure a smooth transition and provide the new MCO/PIHP with the individual’s current service plan. ii. MLTC Eligibility. MLTC plans conduct the initial programmatic eligibility determination for plan enrollment using a standardized assessment tool designated by the state. The following requirements apply to the activities that must be undertaken by an MLTC plan as it assesses applicants for enrollment in the plan. 1. The state shall ensure all individuals requesting long-term services and supports are assessed for MLTC eligibility. a. The MCO/PIHP will use the Semi-Annual Assessment of Members (SAAM) tool (or successor tool designated by the state) to determine if the individual meets the eligibility criteria to be enrolled in an MLTC. b. In addition to the SAAM tool, the MCO/PIHP may use other assessment tools as appropriate. The state must review and approve all other assessment tools used by the MCO/PIHP. c. The state must ensure, through its contracts, that each MCO/PIHP must complete the initial assessment in the individual home of each individual referred to or requesting enrollment in an MLTC plan, within 30 days of that referral or initial contact. MCO/PIHP compliance with this standard shall be reported to CMS in the quarterly reports as required in STC 62. 2. The MCO/PIHP shall complete a re-assessment at least annually, or at another timeframe as specified in the MCO/PIHP contract. 3. The state shall require each MCO/PIHP, through its contract, to report to the enrollment broker the names of all individuals for whom an assessment is completed. If the individual has not been referred by the enrollment broker, the MCO/PIHP shall report the date of initial contact by the individual and the date of the assessment to determine compliance with the 30-day requirement. a. The state shall use this information to determine if individuals have been wrongfully determined ineligible. b. The state shall review a sample of those assessments at least annually, either through the EQRO or by the state, to verify the correct determination was made.

MLTC enrollment. Including the protections afforded individuals in subparagraph (c) of this STCSTC 25, the following requirements apply to MLTC plan enrollment. i. Transition of care period. : Initial transition into MLTC from fee-for-for- service: . Each enrollee who is receiving community community-based long-term services and supports that qualify qualifies for MLTC must continue to receive services under the enrollee’s pre-existing service plan for at least 90 days after enrollment, or until a care assessment has been completed by the MCO/PIHP, whichever is later. Any reduction, suspension, denial, denial or termination of previously authorized services shall trigger the required notice under 42 CFR § 438.404 which clearly articulates the enrollee’s right to file an appeal (either expedited, if warranted warranted, or standard), the right to have authorized service continue pending the appeal appeal, and the right to a fair hearing if the plan renders an adverse determination (either in whole or in part) on the appeal. For initial implementation of the auto-assigned population, the plans must submit data for state review on a monthly basis reporting instances when the plan has issued a notice of action that involves a reduction of split shift or live-in services, services or when the plan is reducing hours by 25% 25 percent or more. The plan will also report the number of appeals and fair hearing hearings requested regarding these reductions. The state shall ensure, ensure through its contracts, contracts that if an enrollee is to change from one MCO/PIHP to another, the MCO/PIHPs will communicate with one another to ensure a smooth transition and provide the new MCO/PIHP with the individual’s current service plan.